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Charles B. (Charles Boyd) Kelsey.

Surgery of the rectum and pelvis online

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the chief cause of death after surgical operations upon the rectum.
I have fortunately met it but few times, though I have seen it follow
the division of a small fistula in hospital and end fatally.

Even with very diffuse inflammation death may not always be the
immediate result. In one case of internal proctotomy for stricture
the chill and inflammation set in at the usual time, when it comes at
all — about the third day. In this case I had great hopes of saving
the patient, as the abscess was plainly visible in the ischio-rectal



PROCTITIS ATSTD PERIPROCTITIS. ' 71

fossa and was freely cut. Large masses of black, sloughing cellular
tissue were discharged through the incisions, but no healthy pus.
In a few days openings formed between the abscess and the rectum.
The patient dragged on for several months, but there was never any
healthy reparative action, and he was finally worn out by repeated
hemorrhages from the erosion of small vessels and by a communica-
tion formed between the rectum and bladder. On the autopsy there
seemed to be no part of the pelvis whicli had not been invaded by
the disease.

I have also seen a cold abscess form around a cancerous stricture
without giving rise to any symptoms, and progress till death re-
sulted in exactly the same way — exhaustion and opening into the
bladder.

This is the complication which, in spite of antisepsis, sometimes
occurs after operations upon the rectum, and whicli it is the one
object of the surgeon to avoid. In the acute form it is analogous to
puerperal septicsemia. In its general symptoms it follows closely
the clinical history of pygemia.

In the way of prophylaxis much may be done by antisepsis
during and after all operations on the rectum. There is no operation
on the rectum too trivial to be done with care and cleanliness ; and
yet the capital operations which are now matters of daily occurrence
show what results may be obtained by proper attention to these
details. This is not the place to go into the details of each surgical
operation, but I have learned the greatest single element in prophy-
laxis to be the careful attention to all antiseptic precautions. A cut
should, moreover, never be made through the rectal wall into the
cellular tissue without at the same time allowing for the free escape
of all the discharge from such a cut by a division of the sphincters.

In the way of treatment for periproctitis, life may be saved by free
incisions and antiseptic irrigations where the inflammation shows
any tendency to become circumscribed ; but otherwise the disease is
fatal.

Gangrenous Cellulitis. — There is a form of gangrenous cellulitis
which sometimes affects the ischio-rectal region. It is a rare disease
and is generally idiopathic. In it there is no pus formed, but the
cellular tissue and the skin over it become necrosed and slough in
large, black masses. The adjacent portion of the rectal wall may be
involved and the rectum be laid open for a considerable extent. The
disease is attended with fever and great prostration ; the tendency to



72 SURGEEY OF THE RECTUM AND PELVIS.

relapse and extension is marked, and the cavit}^ left after separation
of the slough closes very slowly. Jordan, who has given a short
clinical report of a few cases, has always seen it in large, heavy men
who eat too much and drink heavily. In such, a very slight irrita-
tion, such as is caused by sitting on a wet seat, is sufficient to start
the trouble. These cases not infrequently end fatally from extension
of the gangrene into the pelvis, or exhaustion. The treatment con-
sists in early and free incisions and in supporting the powers of the
patient.

The other forms of periproctitis— those which are not due to sur-
gical operations and are distinctly circumscribed— will be treated of
under the head of Abscess.



CHAPTER YI.

ABSCESS.

Abscesses in the region of the anus and rectum are best classi-
fied according to their anatomical location into superficial, ischio-
rectal, and pelvic. Of each of these there are several different
varieties.

Considering first the superficial variety, the simplest form will be
found to be that which involves the skin of the margin of the anus
alone, and which generally originates in one of the minute glands of
the part. Such an abscess may be due to traumatism, or to any
irritation — such as the use of improper paper after defecation, pro-
longed walking or horseback riding, a menstrual discha.rge, or a dis-
charge due to diarrhoea or dysentery — to suppuration beneath an
inflamed pile, or to the presence of a caseating tubercular nodule.
I have several times seen it follow injections of carbolic acid into
hemorrhoids, the pus forming beneath the mucous and muscular
layers and burrowing downward to the anus till it lay superficially
over the sphincter.

This form of disease is always distinctly circumscribed, is gen-
erally about the size of an almond, is found by preference in robust
persons, more often in men than women, seldom in old people, and
almost never in children. It generally goes on rapidly to suppura-
tion, breaks spontaneously on the cutaneous or mucous surface, and
heals without the formation of fistula ; though in cachectic patients it
may pursue a contrary course, the skin over it becoming thin and
violet-colored, and finally rupturing, leaving a permanent sub-
cutaneous fistula, which by subsequent burrowing may reach a
considerable size. Such is apt to be the course in the cases arising
from the injection of carbolic acid.

The treatment of such an abscess consists chiefly in the attempt
to avoid the formation of a fistula, and the best means for accom-
plishing this end is an early incision as soon as suppuration appears



74 SURGERY OF THE RECTUM AND PELVIS.

inevitable. Resolution is hardly to be expected, but it may be
sought for by the use of laxatives, rest in the horizontal posture, and
the application of a bladder of ice. The incision should be large
enough to allow of the free exit of pus, and after it has been made
the part may be poulticed for a day or two, and the abscess cavity
then dressed with lint, care being taken to keep the lips of the in-
cision separated.

Another frequent cause of superficial abscess is the acute in-
flammation and suppuration of an external hemorrhoid, which gener-
ally comes on after an attack of constipation and straining at stool,
or may be due to the same causes as the last. The suffering caused
by such a condition, as by the one last described, is out of all pro-
portion to its apparent importance, and is sufficient to incapacitate
a person of sensitive organization from all accustomed duties. The
remains of former external hemorrhoids are always liable to this ac-
cident, and by the proper abortive treatment the inflammation may
sometimes be overcome without suppuration. If, however, suppura-
tion appears to be inevitable, a small, sharp-pointed bistoury should
be quickly passed through the little tumor.

There is also a form of superficial abscess which lies nearer to the
mucous membrane than the skin, and is due to the acute inflamma-
tion of an internal hemorrhoid, either just at the verge of the anus
or within the sphincter. This is in reality a circumscribed phlebitis
in a venous pouch which is shut off from the general circulation. A
circumscribed, tense, exquisitely painful tumor is formed, varying in
size from a grape to an almond, which, after a few days of suffering,
ruptures spontaneously and allows the escape of a small quantity of
pus. Such an abscess, when within the bowel, is always liable, as
will be shown later, to result in the formation of a blind internal flstula
or of a chronic ulcer if left to its own course, and should, therefore,
be treated by early incision.

There is still another variety of superficial abscess, more serious
in its consequences than those already described, for the reason that
it affects the subcutaneous tissue and not the skin, and is diffuse and
not circumscribed. The symptoms of this form of disease vary
greatly in different cases. In cachectic persons pus may form in large
quantity and break into the bowel with very slight local or general
symptoms, and a blind internal fistula may result. The diagnosis is
generally easy. There will be the usual pain, tenderness and swell-
ing ; and, if the pain be not too severe to admit of the attempt, flue-



ABSCESS- 75

tuation may be obtained by introducing one finger into tlie rectum
and making counter-pressure with the other hand outside.

There is little use in hoping for resolution in an abscess of this
kind, and all active attempts to cause it will be found to do harm
rather than good. The proper treatment is an early free incision. If
pus has already formed or the skin has begun to grow thin over the
abscess cavity, the incision should be free enough to allow of the
easy escape of the contents, for in this way only can the formation
of a fistula be avoided. In such a case drainage should be resorted
to after the incision, and every effort should be made to secure heal-
ing from the bottom of the cavity.

Iscliio-rectal Abscess. — An abscess of the ischio-rectal fossa is
bounded by the levator ani miiscle superiorly, and by the skin
below, with the rectum on one side and the adjacent portion of the
pelvis on the other.

The causes of ischio-rectal abscess are various. Traumatism in
some form accounts for many, and the injury may be either from
within or without. Kicks, falls, wounds by the point of a syringe,
perforation of the bowel by pins and fish bones, operations for
hemorrhoids, and injections of carbolic acid into them, have all been
followed by this complication. They may also result from rupture,
ulceration, or perforation of the rectal wall in connection with strict-
ure. Finally, they may be due to a tubercular deposit in the wall
of the gut which has softened and caused perforation. This is a fre-
quent cause of blind, internal fistulse.

An abscess of the ischio-rectal fossa shows itself with all the
usual symptoms of acute inflammation and can hardly be mistaken
for anything else. It may begin with chill and considerable con-
stitutional disturbance, there will be severe pain, and the skin will
be hard, red, and cedematous sometimes over a considerable part of
the buttock. The pus, if allowed to take its own course (which it
never should be), generally finds its way both to the cutaneous and
mucous surfaces, and a complete and deep fistula results. It may,
however, tend upward in the perineum, being less confined in that
direction, and the prostate and urethra may be pressed upon, causing
retention of urine. Retention of urine is by no means an uncommon
result of this condition, and I have known it to result fatally before
its existence was even suspected.

The prognosis of ischio-rectal abscess depends almost absolutely
upon the treatment adopted. If it be poulticed and allowed to



76 SURGEEY OF THE EECTU3I A^'D PELVIS.

take its own course; a fistula of greater or less extent is tlie certain
result.

There is but one proper treatment for tliis form of trouble, and
that is an early and free use of the knife. It may be considered a
rule that an acute infiammation in this region will go on to suppura-
tion, and hence that antiphlogistic measures adopted with a view of
securing resolution are useless. As soon as the hard, brawny swell-
ing appears, therefore, and without waiting for the pointing of pus,
it should be freely and deeply incised. Ether will be necessary to
perform this operation properly. A long, fine, straight bistoury
should be inserted into the centre of the swelling and pushed for-
ward till pus issues by the side of the blade. It may be necessary to
carry the point fully four inches upward and to repeat the puncture
more than once befoj-e pus is found. Then make an incision from
two to three inches in length through skin and cellular tissue. Into
this the index finger should be passed, all sloughing tissue should
be broken down, and all pockets opened up till it is certain that a
free communication of all parts of the abscess with the external
wound has been established. Wash out the abscess cavity with a
solution of bichloride 1 to 2,000 till no more pus or debris can be seen
in the returning injection. The cavity should be packed with iodo-
form gauze and tlie wound dressed antiseptically. After a few days
of antiseptic dressing the surgeon can judge whether the cavity is
closing promptly or whether the case is to be a long one, only heal-
ing by a slow process of granulation. In the former condition the
antiseptic dressings may be continued till healing is complete ; in the
latter they may as well be abandoned and the cavity left to its own
course, care being taken to prevent burrowing by drainage and free
escape of pus. Though by this line of treatment I have frequently
avoided the formation of fistula, I have not had much success in se-
curing rapid closure of the abscess cavity, and healing has usually
required many weeks. Should another opening form after a free in-
cision, as it sometimes will, the surgeon need not reproach himself.
Pus often has a way of finding its own exit in spite of any -plain
road which may be laid out for it with a knife.

These abscesses should not at first be laid open into the rectum.
unless they have come vevy near to the rectal surface — a point
which is generally misunderstood in practice because of the con-
founding of an abscess which may ultimately result in a fistula
with fistula itself. The treatment is that of abscess, and not



ABSCESS. 77

that of fistula, and is especiall}^ directed toward the prevention of
fistula.

Should the abscess have been neglected till it has opened exter-
nally, it is still essentially an abscess and not a fistula, and the treat-
ment described may still be carried out with a fair prospect of suc-
cess in avoiding an opening into the bowel. I wish to emphasize
this point strongly, for I have seen very unfortunate results follow
free division of both sphincters for deep abscess, and it is a step
which should always be avoided if possible. That it is possible in
this class of cases I have occasionally proved to my own satisfaction,
and I do not hesitate now to try every means with which I am ac-
quainted, at any cost of time to the patient, before resorting to the
usual plan of dividing everything between the abscess cavity and the
bowel.

If, however, the case has been neglected till an internal opening
has formed and the skin over the ischio-rectal fossa has also become
perforated — if, in other words, several days or even weeks have gone
by — the abscess will ^Drobably have to be laid open into the gut to
secure satisfactory healing. The rule of practice must depend upon
the amount of tissue between the abscess and the cavity of the gut.
If there is enough of this, so that there is a fair chance that perfor-
ation will not occur, the case is to be treated simply as an abscess
and independently of the gut. If, on the other hand, perforation is
probable, the case may be treated as a fistula from the outset, as
fistula is sure to occur. Of course, errors in judgment may occur,
and a second operation may on this account become necessary.

Deeip Pelvic Abscess. — The levator ani muscle forms a true dia-
phragm to the pelvis. Pus which forms below it is easih^ evacuated
by the knife or discharges spontaneously upon the surface of the
perineum or within the rectum, and although incurable fistulc3e may
result, life is seldom endangered.

Between this diaphragm of the pelvis and the peritoneum which
is in relation with it on the pelvic side, there is a considerable space
filled with loose connective tissue.

Abscesses in this location may assume vast proportions, burrowing
laterally into the subperitoneal connective tissue of the iliac fossae,
or almost anywhere else in the true pelvis ; discharging into the blad-
der, or rectum high up ; mounting above the bladder or pointing in
the groin or loin, passing downward out of the pelvis into the thigh,
and causing retention of urine or intestinal obstruction by pressure.



to SUKGEKY OF THE RECTUM AND PELVIS.

Pelmc Abscess in the il/aZe.— These abscesses are due to tlie same
causes as those last described and to some others. They may be sec-
ondarj'^ to diseases of the urinary organs, such as gonorrhoea, acute
inflammation of the prostate, or rupture of the urethra and extrava-
sation of urine.

Tlie perforation of the gut by a rectal bougie or by the point of a
syringe, and the landing of an enema in the perirectal cellular tissue,
will set up this, form of disease. It may be a result of appendicitis,
and it may be in its origin entirely disconnected with tlie rectum,
and due to disease of some neighboring part, or to necrosis of some
adjacent bone of the pelvis or spine. In the latter case, the abscesses
are generally of the variety known as cold abscess, and are apt to
be preceded for a long time by pain at the point of disease in the
bone. These may be diagnosticated by microscopic examination of
the pus discharged and a search for bone debris.

The symptoms are often obscure and far from characteristic.
There is more or less vague pain in the pelvis and lumbar region,
which is seldom intense and generally increased by defecation. Fever
may be entirely absent, is seldom continuous, and chills are only
occasionally met with when pus is formed. On the other hand, the
patient may soon sink into a typhoid condition Avith high tempera-
ture and diarrhoea. Vesical symptoms are more marked than intes-
tinal ones, for there is apt to be great vesical irritation with incon-
tinence or retention of urine. There are but two ways of making the
diagnosis. The first is by examination of the rectum and discovery
of the phlegmon ; the second is b}^ finding that the joatient has evacu-
ated a large quantity of fetid pus by the rectum or bladder. The
same condition in the female leads naturally to a pelvic examination,
but I have known a man to wander from one hospital to another for
weeks without examination and hence without diagnosis.

Even when the diagnosis of the existence of the condition has
been made, it maybe impossible for a time to determine its origin, for
psoas abscess, abscess from hip disease, periproctitis, and perinephri-
tis may each cause a collection of pus in the pelvis.

The prognosis is necessarily grave. In the beginning the patient
is exposed to all the dangers of septicaemia, and the immediate re-
sults being favorable the ultimate ones may still be disastrous, being
those which always attend upon prolonged suppuration— chronic in-
validism, visceral complications, anyloid degeneration of the liver
and kidneys, and tubercular deposits. In the comparatively small



ABSCESS. 79

number of cases in which spontaneous healing occars the patient
still may have to meet the results of extensive cicatiicial contraction.
There may be stricture on the one hand or incontinence on the other.
The rectal stenosis may be so great as to cause complete obstruction.

Regarding the termination of these abscesses, Segoud has collected
important statistics. Thirty-five perforated the urethra, and seventy-
seven other parts ; generally the rectum, but occasionally the peri-
neum, the ischio- rectal fossa, and the obturator foramen. Twenty
per cent, are fatal, and many leave fistulous communications with
the urethra or rectum which are never cured.

The treatment of deep abscess in men may now be described in
two words — incision and drainage. The incision should be made as
soon as the diagnosis of the presence of pus is reasonably estab-
lished. It is true that these abscesses tend naturally to discharge
themselves into the rectum or bladder, and that by waiting for this
an operation may often be avoided ; but this by no means constitutes
a cure, rather, on the contrary, a life of chronic invalidism. If the
pus be approaching the surface through the perineum, the incision
should be made here ; if toward the rectum, it should be met through
that cavity ; should it appear in tlie groin or thigh, free incisions
must be made for its outlet ; and should a tumor arise in the iliac
fossa or above the bladder, the operation must be done through the
abdomen. The incision must be free enough to allow of the escape
of all the contents, washing out the abscess cavity, and the estab-
lishment of thorough drainage.

Zeller has advocated a perineal incision whenever possible, even
after pointing has taken place into the rectum. He objects, very
properly, to the incision into the rectum that it is too small, does
not tap the abscess at the most dependent part, is not free from risk
of hemorrhage, and does not prevent the formation of urethro-rectal
fistula, which is much more intractable than urethro-perineal fistula.
From my own experience I should judge that to reach pus by a
perineal incision would seldom be practicable, and yet I have seen a
free opening into the rectum refuse to heal in spite of dilatation and
drainag-e.



CHAPTER YII.

PELVIC ABSCESS IN WOMEN.

Many of the causes already enumerated as acting to produce
pelvic abscesses in men are also effective in vi^omen, but their influence
is hardly to be considered in comparison with the two great causes —
septic and gonorrhoeal inflammation, extending from the endometrium
through the Fallopian tube, to the pelvic peritoneum. As a rule
there is no pelvic cellulitis, and hence no pelvic abscess, not preceded
by a peritonitis ; and hence the consideration of pelvic abscess in
women includes the considei'ation of all that group of conditions
which make up so large a proportion of what is called the "diseases
of women" — salpingitis, pyosalpinx, abscess of the ovary, pelvic
peritonitis, pelvic cellulitis, perimetritis, and parametritis.

The two most frequent exciting causes of pelvic abscess in women
are gonorrhoea and septic poisoning following the puerperal con-
dition. Both of these act by setting up first an endometritis which
extends by direct continuity to the Fallopian tube, thence to the
pelvic peritoneum, and finally to the pelvic cellular tissue. The
amount of inflammation excited, the extent to which it reaches, and
the number of structures involved in its course, depend entirely
upon the virulence of the infection.

It can hardly be denied also that there is a class of post-partum
pelvic inflammations in which no such direct extension of the inflam-
mation can be demonstrated — cases so acute and so virulent that
death supervenes within a few days, and in which the septic poison-
ing seems to be directly from the endometrium to the body of the
uterus, the pelvic peritoneum, and the cellular tissue through the
lymphatics.

When the inflammation extends into the pelvic cellular tissue
there is an efi'usion of inflammatory products, which may subse-
quently undergo absorption or break down into suppuration.
Whether these abscesses are original!}^ extraperitoneal, or whether




Fig. 45. — Pelvic Abscess in Female, Causing Stricture of the Ructum and Intestinal Obstruction.
6



82 SURGEEY OF THE RECTUM AND PELVIS,

in every case the abscess is lirst formed within the peritoneal cavity
and subsequently extends to the extraperitoneal cellular tissue, is a
point which has been much discussed. Doubtless it is true that in
the great majority of cases pus is only found in the cellular tissue
as a direct extension from a focus of suppuration which is anatomic-
ally within the peritoneal cavity. The suppuration after once in-
vading the cellular tissue may extend to any part of the pelvis ; and,
as in the male, may find an exit at a point far removed from the
original point of infection. These abscesses when they open spon-
taneously generally do so into the rectum, vagina, or bladder ; but
there is no limit to their burrowing, and they may open at any point
between the thorax and the thigh.

The symptoms of pelvic abscess in women, though perhaps not
more marked than in men, are much better appreciated, for the reason
that the disease has been more carefully studied and its dependence
upon uterine disease is better understood. TLey are those of pelvic
inflammation, beginning generally with gonorrhoea or puerperal sep-
sis, and going on to hemorrhage, fever, pain, and uterine discharge,
with chill, rapid pulse, tender and swollen pelvis, and the well-known
signs of septic poisoning. By the symptoms alone it is impossible to
tell to what extent the inflammation may have extended and exactly



Online LibraryCharles B. (Charles Boyd) KelseySurgery of the rectum and pelvis → online text (page 7 of 41)